Personality Disorders: Theory, Research, and Treatment

Personality Disorders: Theory, Research, and Treatment

Empathy in Narcissistic Personality Disorder: From Clinical and Empirical Perspectives

Arielle Baskin-Sommers, Elizabeth Krusemark, and Elsa Ronningstam Online First Publication, February 10, 2014.

CITATION Baskin-Sommers, A., Krusemark, E., & Ronningstam, E. (2014, February 10). Empathy in Narcissistic Personality Disorder: From Clinical and Empirical Perspectives. Personality Disorders: Theory, Research, and Treatment. Advance online publication.

This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly.

Personality Disorders: Theory, Research, and Treatment 2013, Vol. 5, No. 1, 000

? 2014 American Psychological Association 1949-2715/13/$12.00 DOI: 10.1037/per0000061

Empathy in Narcissistic Personality Disorder: From Clinical and Empirical Perspectives

Arielle Baskin-Sommers

Harvard Medical School, McLean Hospital

Elizabeth Krusemark

University of Wisconsin-Madison

Elsa Ronningstam

Harvard Medical School, McLean Hospital

Narcissistic personality disorder (NPD) is associated with an assortment of characteristics that undermine interpersonal functioning. A lack of empathy is often cited as the primary distinguishing feature of NPD. However, clinical presentations of NPD suggest that empathy is not simply deficient in these individuals, but dysfunctional and subject to a diverse set of motivational and situational factors. Consistent with this presentation, research illustrates that empathy is multidimensional, involving 2 distinct emotional and cognitive processes associated with a capacity to respectively understand and respond to others' mental and affective states. The goal of this practice review is to bridge the gap between our psychobiological understanding of empathy and its clinical manifestations in NPD. We present 3 case studies highlighting the variability in empathic functioning in people with NPD. Additionally, we summarize the literature on empathy and NPD, which largely associates this disorder with deficient emotional empathy, and dysfunctional rather than deficient cognitive empathy. Because this research is limited, we also present empathy-based findings for related syndromes (borderline and psychopathy). Given the complexity of narcissism and empathy, we propose that multiple relationships can exist between these constructs. Ultimately, by recognizing the multifaceted relationship between empathy and narcissism, and moving away from an all or nothing belief that those with NPD simply lack empathy, therapists may better understand narcissistic patients' behavior and motivational structure.

Keywords: narcissistic personality disorder, emotional empathy, cognitive empathy, grandiose, vulnerable

Narcissism and empathy have long been considered interrelated. factors (e.g., low self-esteem, sense of internal control, self-

From the early clinical conceptualizations of narcissistic person- enhancement, emotion intolerance, self-centeredness) may co-

ality disorder (NPD) to the introduction of NPD in the DSM?III occur and affect the narcissistic individual's empathic capability

(APA, 1980), impaired empathic processing has been considered a hallmark of pathological narcissism and NPD (Adler, 1986; Akhtar, 1989, 2003; Cooper, 1998; Kernberg, 1983, 1985; Kohut, 1966; Ronningstam, 2005; Watson, Grisham, Trotter, & Biderman, 1984; Watson & Morris, 1991). Most often, "lack of empathy" is included as a signifier of the diagnosis and is highlighted in both the clinician's and lay public's impression of narcissistic individuals.

However, clinical research efforts using self-report and interview measures have failed to identify lack of empathy as a distinguishing characteristic in patients with NPD (Ronningstam & Gunderson, 1988, 1990; Ronningstam, Gunderson, & Lyons, 1995). Moreover, a growing body of work indicates that several

and functional pattern (Campbell, Reeder, Sedikides, & Elliot, 2000; Fonagy, Gergle, Jurist, & Target, 2002; Fonagy & Luyten, 2009; Fonagy, Steele, Steele, Moran, & Higgitt, 1991; Nezlek, Schutz, Lopes, & Smith, 2007; Ronningstam, 2009; Schore, 1994; Watson, Little, Sawrie, & Biderman, 1992). This accumulation of evidence spurred the description of empathic dysfunction to change from the inability to recognize how others feel in the DSM?III classification, to the unwillingness to recognize or identify with the feelings and needs of others in DSM?IV (APA, 1994). This shift underscored a specific motivational aspect of empathy in narcissistic personality functioning. Stone (1998), however, further qualified this narcissism? empathy relationship, suggesting that there could be separable aspects of ability and willingness that

affect narcissistic individuals' empathic functioning. That is, some

narcissistic individuals may have intact empathic ability, but

Arielle Baskin-Sommers, Department of Psychiatry, Harvard Medical School, McLean Hospital; Elizabeth Krusemark, Department of Psychology, University of Wisconsin-Madison; Elsa Ronningstam, Department of Psychiatry, Harvard Medical School, McLean Hospital.

Correspondence concerning this article should be addressed to Arielle Baskin-Sommers, McLean Hospital, 115 Mill Street, Belmont, MA 02478.

choose to disengage from others' pain or distress, while others may have a deficient ability in the recognition of others' feelings.

From a theoretical and clinical perspective, growing evidence suggests that the narcissism? empathy relationship is not all or none, but instead is a more complex relationship reflecting fluctuations in empathic functioning within and across narcissistic

E-mail: abaskinsommers@

individuals. Consistent with the understanding that narcissism may

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BASKIN-SOMMERS, KRUSEMARK, AND RONNINGSTAM

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reflect variations in empathic functioning, the DSM-5 Personality Disorder Work-Group introduced a new conceptualization of empathy. Considered a dimensional component in Interpersonal Functioning (Criterion A), empathy is defined as a capability that may be deficient and entail moments of fluctuation depending on the specific situation. For NPD, the following conceptualization of empathic functioning was suggested: "Impaired ability to recognize or identify with the feelings and needs of others; excessively attuned to reactions of others, but only if perceived as relevant to self; over- or underestimate of own effects on others." Although the diagnostic criteria for personality disorders will remain unchanged in DSM-5 Section II, an alternative Section III, representing the significant work on reconceptualizing and improving the diagnosis of personality disorders including NPD, has been incorporated awaiting additional empirical validation (Skodol et al., in press).

The purpose of this review is to examine the current empirical work on empathic functioning as it relates to pathological narcissism and NPD in order to better understand this relationship. In this review we: (a) provide a psychobiological overview of empathy and its subcomponents; (b) summarize existing empirical findings on the empathy and narcissism relationship, and given the paucity of empirical work in this field, also review research on near-neighbor personality conditions (e.g., borderline and psychopathic); (c) present three case studies of narcissistic individuals, focusing on segments from developmental history and therapy sessions that highlight the relationship between narcissism and empathy; and (d) discuss clinical and treatment implications of the empathy?narcissism relationship within our proposed framework.

Empathy: Psychobiology and Subtypes

Empathy is a multifaceted construct that involves both the affective experience of the other person's actual or inferred emotional state and the recognition and understanding of another's emotional state (Decety & Moriguchi, 2007). It also involves the ability to monitor oneself and to maintain and regulate self-other awareness (Funder & Harris, 1986). Unlike related processes such as sympathy, the essence of empathy reflects the ability to separate oneself from others' experiences and recognize possible emotions and alternative perspectives. Empathy typically emerges within the second year of life and greatly depends on the nature of human interactions (e.g., caregivers' style, family environment) to support self-other awareness and conscious concern for others (Decety & Svetlova, 2012; Svetlova et al., 2010; Vaish et al., 2009). Other factors such as temperament and genetics also influence the development of empathy (Zahn-Waxler et al., 2001). Thus, both genetic and environmental effects shape empathetic processing.

From a neuroscience perspective, there are multiple empathic processes that, to a certain extent, are associated with dissociable neural systems. Specifically, there are two main subdivisions of empathy: emotional and cognitive. Emotional empathy includes response to affective displays by others (e.g., facial expressions) and emotionally evocative stimuli (e.g., phrases, stories). Cognitive empathy, or Theory of Mind, refers to the understanding and representation of mental states (i.e., belief, desire, and knowledge) that enables an individual to explain and predict others' behavior. Moreover, some researchers add a third division of empathy, motor empathy, which is associated with mirroring the motor

responses of other's (Preston & de Waal, 2002). However, due to the current inability to measure individual (e.g., mirror) neurons in humans, we will not review motor empathy (see Blair, 2005 for review).

Emotional empathy is associated with partially separable systems (all requiring superior temporal cortex) that are activated (show increased activation) depending on whether the individual is responding to fearful/sad/happy (amygdala), disgust (insula), or angry (ventrolateral prefrontal cortex) expressions. Adolphs et al. (2005) examined amygdala-lesioned patients and found that consistent with the role of the amygdala in facilitating the fear expression, these patients showed impairment in the recognition and experience of fear. Similarly, damage to the insula, a region crucial in monitoring body state, can impair both the experience of disgust and the recognition of social signals (e.g., facial expression) that convey disgust. Consistently, functional neuroimaging studies show that observing facial expressions of disgust and feelings of disgust activated very similar sites in the anterior insula and anterior cingulate cortex (see Decety & Jackson, 2004, for review).

Factors such as attachment style and temperament moderate the development of emotional empathy and its related neural capacities. From an early age, even prior to the onset of language, infants communicate with others in their environment by reading and generating facial expressions (Lepp?nen & Nelson, 2009). These components of emotion are present at birth, relying on close connections between perceptual processing and emotion-related neural circuits, and prepare the individual for later empathic connections through affective interactions with others. Given that infants' social interactions begin with a primary caregiver, the empathic capability of the caregiver is crucial for secure and healthy attachment to develop. To the extent that children develop secure attachment, they develop more responsivity to the needs of others (Mikulincer et al., 2003). Additionally, infant arousal in response to other's affect can influence social learning and reinforce the infant's own emotionality. Consequently, temperamental emotionality (i.e., degree of physiological and affective reactivity) is purported to underlie the genetic heritability of emotional empathy and neural reactivity in the amygdala (Davis, Luce, & Kraus, 1994; Vrticka et al., 2008). For example, 4-month-old infants who showed relatively low levels of affective responses to novel sensory stimuli, were found to respond less empathically to a stranger simulating distress at age 2 (Young et al., 1999). The low reactivity to sensory stimuli in infancy and others' distress in toddlerhood may be early signs of underarousal that influences the development of insensitivity and antisocial behavior.

In contrast to the affective neural basis (i.e., subcortical) of emotional empathy, cognitive empathy is associated with a network of cortical regions, which include the medial prefrontal cortex, the temporal-parietal junction, and the temporal poles (Brunet, Sarfati, Hardy-Bayle, & Decety, 2000; see Frith, 2001 for review). For example, Saxe and Kanwisher (2003) developed four conditions (i.e., stories that examine false belief, human action, nonhuman inferences, and mechanical inferences) to isolate Theory of Mind-related neural processing. More specifically, only the false belief and human action stories elicited Theory of Mind reasoning and stimulated greater activity in the superior temporal sulcus, precuneus, and the temporal-parietal junction (see also Saxe & Powell, 2006; Mitchell, 2008). Additionally, the anterior superior temporal sulcus and the temporal-parietal junction were

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also activated in a condition designed to assess the participant's understanding of the protagonist's desire (Saxe & Powell, 2006).

There is ample evidence demonstrating that the emotional component of empathy develops earlier than the cognitive component, and that cognitive empathy is primarily related to the development of executive functioning (e.g., working memory, inhibitory control), language capabilities, metacognition, and cortical brain maturation (Carlson et al., 2004; Eisenberg & Eggum, 2009; Meins et al., 2002; Tamm et al., 2002; Zelazo et al., 2004). For example, in a study with 3- and 4-year-old children, performance on inhibitory control tasks was significantly related to Theory of Mind capabilities (Carlson & Moses, 2001) and executive functioning at 3? 4 years predicted quality of Theory of Mind processing 1 year later (Hughes, 1998). Together, these studies suggest that the development of cognitive-based processes, such as inhibitory control, is crucial for cognitive empathy.

From a psychobiological perspective, it is evident that empathy is a complex process influenced by both biological and environmental factors, and attributed to partially separable neural systems (e.g., all empathic processes appear to activate the superior temporal cortex, but each subprocess then activates additional regions). Identifying separable cognitive and affective processes is important when considering the relationship between empathy and psychopathology, particularly as these processes relate to narcissism.

Empirical Evidence for Compromised Empathy in Narcissism

As noted above, from a phenotypic perspective, compromised empathic processing is a hallmark of narcissism. However, only a few empirical studies have closely examined the association between empathy and narcissism (Munro, Bore, & Powis, 2005; Porcerelli & Sandler, 1995; Trumpeter et al., 2008; Watson & Morris, 1991; Wiehe, 2003; Watson et al., 1995, 1992, 1984). Little research has been done with narcissism to directly measure the neural processes implicated in empathy, but a handful of studies have explored the resultant behaviors associated with emotional (e.g., viewing facial expressions, questionnaires directed to asses this component) or cognitive (e.g., Theory of Mind tasks or questionnaires) empathy. Although results are mixed, there is growing evidence that individuals with pathological narcissism or NPD display significant impairments in emotional empathy, but display little to no impairment in cognitive empathy (Ritter et al., 2011; Wai & Tiliopoulos, 2012; Watson et al., 1984).

Studies have shown that individuals with NPD display deficits in recognition of emotion when viewing facial expressions (Marissen, Deen, & Franken, 2012) and in empathic concern and mirroring emotions when viewing emotionally charged situations (Ritter et al., 2011). However, there is not enough evidence to make definitive conclusions that pathological narcissism is associated with differences in cognitive empathy. When completing the video-based Movie for the Assessment of Social Cognition, a measure of Theory of Mind, patients diagnosed with NPD did not differ from healthy controls. Additionally, patients with NPD and healthy controls showed no differences in cognitive empathy as indexed by the Multifaceted Empathy Test (Ritter et al., 2011). Consistent with this specific deficit in emotional empathy, a recent neuroimaging study presented pictures of emotional faces and

asked participants to empathize with the person in the picture. Participants high on narcissistic traits displayed decreased deactivation of right anterior insula during processing of emotional faces (Fan et al., 2011). The authors interpreted this pattern of activation as indicative of an increased self-focus among narcissistic individuals. Another study measuring respiratory sinus arrhythmia and cardiac preejection period reported that pathological narcissism was associated with a decrease in respiratory sinus arrhythmia and preejection period shortening while viewing happy images (Sylvers, Brubaker, Alden, Brennan, & Lilienfeld, 2008). This finding was generally interpreted as a negative reaction to watching others in positive experiences. Lastly, individuals high in narcissism displayed lower electrodermal reactivity in anticipation of aversive events (e.g., noise blast; Kelsey, Ornduff, McCann, & Reiff, 2001), which has been interpreted as insensitivity to contextual anticipatory demands. Taken together, these findings provide preliminary neural and physiological evidence of decreased empathy, specifically emotional empathy, among individuals with NPD.

Although the experimental research on empathy and narcissism is limited, generally, it indicates a stronger deficit in emotional rather than cognitive empathy. An interesting pattern emerges, however, when individuals high on narcissism are asked about their empathic functioning. Research using self-report questionnaires that measure components of empathy, reports that narcissism (both trait and pathological) is inversely related to cognitive empathy (Watson et al., 1992). More specifically, individuals high on narcissism report lower levels of perspective taking on the Interpersonal Reactivity Index (Davis, 1983), particularly in response to questions that assess willingness to engage in empathic concern. Conversely, narcissistic individuals tend to overestimate their capacity for emotional empathy (Ritter et al., 2011). This pattern may indicate that narcissistic individuals, as suggested above, have a motivation-based impairment in their cognitive empathic functioning in addition to compromised emotional empathy. That is, individuals with pathological narcissism may be capable of processing affective information, but don't want to engage in empathic processing so as not to lose control or appear vulnerable (Ames & Kammrath, 2004). Combined with their inability to respond to other's emotions, this may leave narcissistic individuals at a loss for how to connect with others and manage interpersonal interactions.

Empirical Evidence for Compromised Empathy in Related Psychopathologies

Two pathologies that have been linked to narcissism are psychopathy and borderline personality disorder (BPD). Each of these syndromes appears on a continuum with NPD that highlights patterns of impulsivity, emotion dysregulation, and self-centered, goal-focused behaviors. The phenotypic overlap in these pathologies contributes to their moderate levels of comorbidity, with NPD and psychopathy co-occurring at rates of approximately 21% (Blackburn, Logan, Donnelly, & Renwick, 2003) and NPD and BPD comorbidity estimated at 37%39% for BPD (Stinson et al., 2008). Given the paucity of empathy-based work on pathological narcissism, research in other related pathologies may highlight specific empathy-pathology relationships.

Bearing resemblance to NPD, psychopathy is associated with grandiosity, compromised empathic functioning, and callousness.

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Although a pattern of deceitful, manipulative, and impulsive behavior is inherent in the syndrome of psychopathy, these features are not necessarily a component of NPD. However, exploring the relationship between a psychopathic individual's ability to lie and manipulate and their empathic functioning may provide a context for understanding how those with narcissism also can appear callous and grandiose. Similar to research in narcissism, individuals with psychopathy display difficulties with emotional empathy, but display intact cognitive empathy on experimental tasks (Blair, 2005; Hare, 1993; cf., Brook & Kosson, 2013). Psychopathic individuals show reduced autonomic responses to stimuli associated with other's distress (House & Milligan, 1976) and sad expressions (Blair et al., 2005). There is also some evidence of psychopathy-related amygdala dysfunction during emotional memory (Kiehl et al., 2001) and conditioning tasks (Birbaumer et al., 2005). These deficits in amygdala activation along with reduced reactivity to other's distress supports the proposal that psychopathy is related to deficient emotional empathy.

In contrast to the proposed deficit in emotional empathy, a number of studies report normative performance in psychopathic individuals on Theory of Mind (i.e., cognitive empathy) tasks (Blair et al., 1996; Mullins-Nelson, Salekin, & Leistico, 2006; Richell et al., 2003; Widom, 1978). Moreover, recent imaging studies indicate that psychopathic individuals display overactivation of (pre)frontal regions, which in turn, inhibits amygdala reactivity (Larson et al., 2013; Muller et al., 2003). Thus, it may be that psychopathic individuals rely on cognitive inputs (and potentially Theory of Mind processes) to perceive emotions, but have difficulties processing them, resulting in deficient emotional empathy.

In addition to psychopathy, BPD exists within a similar nomological network as NPD. Although BPD is characterized by low tolerance for aloneness, impulsive behavior, and tendencies toward regressive fragmentation; this pattern differs from the tendency of narcissistic individuals to engage in self-enhancement and display a cohesive sense of self. However, both individuals with BPD and those with NPD are reactive to criticism, have trouble keeping healthy relationships, and become easily hurt or rejected (Miller et al., 2010). Although some studies on BPD indicate that these individuals also have a deficit in emotional empathy (Dziobek et al., 2011; Levine, Marziali, & Hood, 1997; Ritter et al., 2011), others show that BPD is related to normative or even hyperreactive emotional empathy (Harari et al., 2010; Lynch et al., 2006; Wagner & Linehan, 1999). Additionally, there is some evidence that BPD is associated with a deficit in cognitive empathy (Dziobek et al., 2011; Harari et al., 2010). Consistent with this imbalance in emotional and cognitive empathy, a number of imaging studies report hyper-reactivity in the amygdala and insula when viewing emotional evocative pictures during a psychological distancing task, or an affective empathy task (Donegan et al., 2003). There is also evidence of hyporeactivity in prefrontal cortices and superior temporal sulcus and gyrus during aggression regulation tasks, possibly highlighting deficient self-relevant reflection in BPD (Dziobek et al., 2011; see Schmahl & Bremner, 2006 for review). Despite the evidence of deficient prefrontal activation, some work reports that borderline individuals perform as well as healthy controls in Theory of Mind tasks (e.g., Reading the Mind in Eyes; Fertuck et al., 2009; Ripoll, Snyder, Steele, & Siever, 2013). Taken together, in the context of empathy, individ-

uals with BPD appear to be overwhelmed by their own emotions, have difficulty regulating those emotions, and as a result have impairment in inferring the mental state of and being emotionally attuned to another.

Across psychopathy, BPD, and NPD, current research suggests that deficient emotional empathy is a key to the problematic empathic functioning in these individuals. Slight variations and comparisons with different disorders suggest that multiple relationships between cognitive and emotional empathy are plausible in NPD. On the one hand, despite being able to perceive emotions in a manner similar to psychopathy, individuals with NPD may have compromised empathic functioning because of a deficit in emotional empathy (e.g., neurobiological evidence) and a deliberate attempt to avoid feeling vulnerable (e.g., self-report data). On the other hand, it is also possible that those with NPD, like individuals with BPD, experience intense emotions (e.g., anger, shame, fear; Cooper, 1998; Gramzow & Tangney, 1992) that impair their ability to attend and react to other's emotions (i.e., deficient emotion tolerance and regulation). Ultimately, the examination of psychobiological, behavioral, and neural underpinnings of empathy provides a basis for future research that may identify the specific dysfunction(s) responsible for the potential disingenuous and indifferent inter- and intrapersonal behaviors of narcissistic individuals.

Clinical Implications

This review highlights evidence for compromised empathic functioning, but not an inability or absence of empathy, in people with pathological narcissism and NPD. Overall, research suggests a neural deficiency in emotional empathy, despite the tendency for narcissistic individuals to overestimate their own emotional empathic capability. At this time, there is little evidence to suggest a reliable deficit in cognitive empathy among narcissistic individuals. Examination of related pathologies, like BPD and psychopathy, however, provide alternatives for the variability observed in empirical and clinical observations of empathy in narcissism. As such, the complexity of narcissism and empathy may suggest that multiple pathways or relationships between these constructs are possible. Below, we present illustrative case studies, from individuals who met five or more of the DSM-5 diagnostic criteria for NPD, that highlight the multidimensional nature of narcissism and empathy.

Case Study #1

Mr. S is a married man and father of two children. Mr. S described to his therapist how he learned to benefit from people, thrive socially, and professionally through his special ability "to attend to and understand" other people. He gave numerous examples of how his "intuition" has led to business opportunities, special privileges, and admiration. Despite his ability to connect with other people, Mr. S. often described his impatience and contempt, especially with some colleagues and with his wife, when they bothered him with anxieties over seemingly trivial things.

Growing up, he had always felt torn between his anxious and demanding father and his friendly and very successful mother. Early on Mr. S learned that in order to gain his mother's appreciation, he would

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